This article is written by Katherine Lawson, her website is dreamsheal.com.
Katherine is trained in Embodied Imagination dreamwork in additon to her M.A. in Counseling Psychotherapy.
This paper deeply moved me even though written for an academic purpose. I had the personal experience of witnessing my sister go through the medical system and the lack of inner world work that could have benefited her while in palliative care and through the hospice program. When my sister died, I went into a deep depression, and it was only the support of a grief group where I could share my dreams that I began to heal. This experience is what led me to become a certified Embodied Imagination Practitioner in hope of working with people in hospice programs. In Embodied Imagination, we are working with what we do not know, in a discovery mode, so it is useful training for the art of dying. As dreams themselves are fleeting, they are a practice of memento mori.
Benefits of Dream Work for the Dying
Katherine B. Lawson
MBM 5690 Complementary & Integrative Medicine
Chanel Heerman, MD
May 16, 2017
This paper provides an examination of the effects of dream work on patients facing end of life. The literature reviewed is an exploration of the value of interaction with dreams though guided dream work techniques as well as using surveys and interviews. Quality of life, comfort, and psychological well-being associated with dream work will also be explored. Additionally, the author will review the research on how dreams and dream content help to mediate the existential crisis faced by those at end of life. The author’s goal is to provide evidence to support the integration of dream work into the existing complementary and integrative practices for palliative care and to highlight the need for further research.
Keywords: Death, dream work, end of life, existential crisis, hospice, palliative care, quality of life.
Effects of Dream Work for the Dying
I have had my ownexperience with facing mortality and deriving benefit from dream work. In 2013, I was diagnosed with cancer. Although it was made clear to me that I had a high likelihood of surviving, I also understood that there was a chance I could perish, if not from the cancer itself, then from the treatment. Naturally, I was plagued with the accompanying fear and anxiety. Almost immediately, however, I had the benefit of doing guided dream work regularly, which eased my most distressing emotional symptoms and, in my opinion, may have even helped my physical healing.
None of the medical professionals I dealt with ever addressed the emotional difficulties that accompanied having cancer and its treatment, nor did they mention therapies that I might employ to mitigate them. I believe this made my situation all the more agonizing. Consequently, I have been interested in complementary treatments that might help those in a similar position. In my experience, dream work as an integrative medicine practice is almost unknown. As my formal psychological training and education up to this point has been focused on depth psychotherapy, I will refer frequently to a Jungian perspective toward working with dreams and healing. I will also examine differing methods and theories as used in the research. I hope to present a compelling argument for using dream work in palliative care as a complementary treatment.
The newsof one’s impending death is both shocking and terrifying. Research has shown that the dream life of those facing end of life intensifies (Devery, Rawlings, Tieman, & Damarell, 2009: Kerr et al., 2014; Wright, Grant, Depner, Donnelly & Kerr, 2015). This intensification is often dismissed as the side effect of pain medications, hallucinations, or hysteria. Additionally, the psychotherapy that most individuals receive while in hospice generally disregards the collective unconscious, depending on a more psychodynamic standard of treatment (McGillicuddy, 2009). However, there is a historical precedent for viewing dreams as having the potential to offer insights toward both growth and healing with the aid of a dream worker, offering the possibility of moving through life’s ending with courage and hope.
History of Dream Work
Asklepios, the ancient Greek god of healing, held that dreams had both a religious and personal and physical meaning. Eventually, the medical aspect became so pervasive as to practically overshadow the religious. Healing sanctuaries devoted to Asklepios spread throughout Greece, Egypt, and later Roman territories. The sick and suffering traveled great distances for dream healing by way of release and purification. Bodily sickness and emotional sickness were considered inseparable at these healing temples. The healing guides used dream images to direct the sufferer’s focus away from the disease and toward the cure (Bosnak, 2007; McGillicuddy, 2009).
Freud viewed dreams as a direct path to the unconscious. However, he viewed dream material to represent repressed thoughts or wishes. Therefore, the therapeutic value in dream work lay in interpreting latent material found in dreams for use in the waking world (McGillicuddy, 2009). Carl Jung defined dreams as “a spontaneous self-portrayal, in the symbolic form, of the actual situation in the unconscious” (1948/1969 [CW8]). To those who study or practice depth psychotherapy, dream images are thought to be one way that the unconscious integrates with waking life situations. Psychological healing is thought to come about by repairing any split between our conscious and unconscious worlds. While there is not a lot of research to support his position, Jung did use dream work as a therapeutic approach in processing the psychological transition of impending death (McGillicuddy, 2009; Wright et al., 2015).
According to Lyons (2012), a researcher who focuses on dream work with cancer patients, during REM sleep, imagery is selected and created in the mind according to memories, emotional associations, and contextual references from our waking lives. She states that the language of dreams is considered to be metaphoric and the images found in dreams are symbolic representations originating from within the dreamer’s psyche. The dream symbol’s potency is not literal, but gained through the very personal relevance they hold for the dreamer. Rather than pointing out an actual illness or impending death, the dream will depict the situation in symbolism that can offer guidance, meaning, and solace (Lyons, 2012).
Lyons (2012) guides dreamers back into a dream in a highly relaxed state. Guided imagery techniques are used to both create a sense of safety and to encourage an experience that embodies all senses. She has found that guided imagery techniques that incorporate personal dream symbolism have shown powerful ability to reduce fear and anxiety in cancer patients.
In my own experience working with dreams using Embodied Imagination (Bosnak, 2007), I have found that guiding and accompanying cancer patients to the dream world have been incredibly rewarding for them. According to the theory of Embodied Imagination, the dream realm is a place of creative imagination that holds images “that embody their own active intelligence” (p. 34). Exploring the perspectives of these images and anchoring them in the body animates the dreamers with new and useful perspectives, often putting them in touch with emotional states and insights that may not be accessible in their waking lives. Using this method with dozens of cancer patients over the past two years, I have seen the potential for the symbols found in dreams to evoke positive changes in the human mind, body and spirit.
Death and Dreaming
In contemporary culture, individuals are likely to die in hospitals or nursing homes. Dying in these institutions can be a lonely and dehumanizing experience. To medical professionals, death is often viewed as a failure. Therefore, quality of life is sometimes compromised by the medical profession’s drive to succeed by saving a life. In Western culture, we are not prepared in life for how to die (McGillicuddy, 2009; Lowther, 2002). There is an unfortunate impression maintained that illnesses may not prove fatal.
Many of those who are facing end of life are encountering one of the most formidable transitions in life and are challenged to find meaning. Conversely, facing one’s own mortality can be bewilderingly productive, often leading one to newfound insights, personal growth and acceptance (Kerr et al., 2014; Wright et al., 2015). In Western culture, the anxiety and denial around mortality have led to a loss of traditional death rituals that allow an honest contemplation or acceptance of death for both patients and families. To compound this loss, McGillicuddy (2009) refers to “a void and lack of soul” that is often expressed by medical providers regarding their training, which may prevent them from offering patients a more peaceful transition (p. 62).
Freud observed that in the unconscious mind, death does not exist, yet he did not believe in an afterlife and was known to fear death. For Jung however, death was considered to be as important an event as birth and to be anticipated with interest. Death, once achieved, he considered to be a “form of existence beyond space and time” (as cited in McGillicuddy, 2009, p. 54), filled with peace and meaning. For this reason, it is from a depth or Jungian perspective that dreams are most commonly viewed as a therapeutic means of achieving psychic wholeness at the moment of death.
Research and Literature
The following review of the literature focuses on near-death dreams, dream work, and the effect of dream work on subjects who are dying, focusing on the various methodologies and results of dream work. The reviewer will examine how dream work affects a patient’s sense of wellbeing, quality of life, and coping skills with regard to feelings of existential crisis and meaning at the end of life.
According to Barbato et al. (2009), the phenomena that present as dreams and visions at the end of a patient’s life can be difficult forhim or her to mention or discuss. Many have concerns about being judged or having their sanity called into question. Caregivers and healthcare professionals can also be at a loss as to how to respond to these often bizarre sounding reports (as cited in Devery et al., 2015). However, most studies reviewed (Devery et al., 2015) failed to support the idea that deathbed phenomena were hallucinations and found them to be comforting to both patients and their families. These outcomes lend support for further research into therapeutically enlisting the mechanisms by which dreams aid those facing death.
Objective.Devery et al. (2009) reviewed the literature on deathbed phenomena (DPB) in hopes of presenting suggestions for a clinical response to patients experiencing these events. They also culled and analyzed data on the characteristics of DBP. The phenomena could include dreams or visions experienced either awake or asleep, seeing heavenly visions, sensing light or warmth, or sensing the presence of a deceased pet or relative.
Method.For this article the authors, who are also palliative care workers (Devery et al., 2015), reviewed 8 studies. Deathbed phenomena were defined as “significant dreams or visions experienced either awake or in a dreaming state” (p.1) by patients whose illnesses were terminal. Reports of DBP were required to be given by patients, proxy or healthcare providers. The populations for the studies were taken from healthcare settings and considered to be in palliative care or at end of life. The review may contain bias due to having used only published journal articles, which were limited in number.
Results.Results showed that most patients experiencing DBPs gained a profound sense of comfort and meaning, despite a reluctance to disclose them to caregivers for fear of ridicule. The experiences were also found to be beneficial to many family members, lending insight to the inner world of their loved ones. Devery et al. (2009) report DBPs as frequently foretelling imminent death and propose that DBP may serve to prepare the dying person for death. Most DBP were reported within one month of death. Both males and females reported experiencing DBP and reports were not culturally or geographically connected.
End-of-life Dreams and Visions
Like deathbed phenomena, end-of-life dreams and visions (ELDVs) have been shown to have meaningful impact on those facing death and on their families. According to a review of the published literature, many palliative care workers frequently believe that ELDVs are an essential element in the dying process. Most published literature on the topic is based on reports or surveys from family members, caregivers, or healthcare professionals. In this study by Kerr et al. (2014), researchers examined the frequency, content, and subjective significance of ELDVs as well as exploring how each of those factors related to proximity to death.
Objective.Although there is not much data examining the pervasiveness, content, or meaning of ELDVs, particularly from a patient’s perspective, Kerr et al. (2014) aimed to document the ELDV experiences of patients in hospice care. They share the content of ELDVs as well as the subjective significance of these dreams and visions over time.
Method.This longitudinal mixed-methods study surveyed patients admitted to the Hospice Inpatient Unit at the Center for Hospice and Palliative Care in Cheektowaga, New York, from January 2011 through July 2012, using a semi-structured interview. Sixty-six patients participated in the study. The semi-structured interview contained both closed and open-ended questions. Questions pertained to content, frequency, and emotional impact of dreams/visions (Kerr et al., 2014). An interviewer used a standard framework of questioning daily until death or discharge.
Inclusion criteria included a Palliative Performance Scale (PPS16). Exclusion criteria were a diagnosis of a psychotic disorder and/or an inability to both speak and understand English. Patients reported on dream frequency and comfort provided by the dream/vision which was rated on a 5-point semantic differential scale with 1 = Extremely Distressing and 5 = Extremely Comforting. Participants were also asked open-ended questions in which the participant was allowed to describe the dream or vision. Self-reports were coded on a checklist with eight categories.
Results. Of the 59 patients who were interviewed, 52 (88.1%) reported experiencing at least one dream or vision (Devery et al., 2009: Kerr et al., 2014; Wright et al., 2015). The researchers propose that the number is potentially higher, as many patients and their families tend to underreport these experiences due to embarrassment or fear of judgment (Devery et al., 2009: Kerr et al., 2014). Almost half of the dreams/visions (45.3%) occurred while awake. As end of life became closer, dreams and visions became more comforting. Nearly all patients reported that ELDV events (267/269, 99%) felt real (Kerr et al., 2014).
Patients rated the degree of comfort/distress associated with their ELDVs on a 5-point scale ranging from Extremely Comforting (5) to Extremely Distressing (1). The mean comfort rating for all dreams and visions was 3.59 (SD = 1.21, 95% confidence interval [CI] = 3.44–3.73) with 60.3% rated as comforting or extremely comforting. Comfort ratings differed depending on ELDV content; F (3257) = 20.54, p < 0.001. This study showed a clear association between ELDVs and degree of comfort with approaching death (Kerr et al., 2014).
Meaning-Centered Dream Work
A primary element of one’s existential state of well-being is a sense of meaning. According to research conducted by Wright et al. (2015), for those facing death, palliative care has been most focused on the physical difficulties while the emotional anguish of the dying may be unintentionally neglected. The pilot study reviewed here is “based on Frankl’s (2006) theoretical assumption that the ability to find or create meaning allows human beings to transcend challenges to freedom, dignity, or personhood, including the prospect of death” and uses this theory in working with the dreams of the dying (as cited in Wright et al., 2015, p. 4).
Objective. According to researchers (Kerr et al., 2014; McGillicuddy, 2009; Wright et al., 2015), those who are dying often struggle with loss of meaning while frequently experiencing vivid dreams. Wright et al. (2015) examined the process of meaning-centered dream work as well as the outcomes with patients at end of life. Their intention was to address the psychological needs of patients in palliative care while employing a meaning-centered approach to dream work and to highlight the need for further research in this area.
Method. A total of twelve dream work sessions were conducted with seven hospice patients whose average age was 69.9 years-old. Participants were referred to the study by members of their palliative care team. They were required to have been previously diagnosed with a terminal illness with a life expectancy of less than 6 months. The researchers excluded patients who were undergoing curative or aggressive treatments (Wright et al., 2015). Session transcripts were analyzed using the consensual qualitative research (CQR) method, which consists of open-ended interview questions, small samples, and a reliance on words over numbers, emphasizing the importance of context, integration of multiple viewpoints, and consensus among the research team. A meaning-centered method of dream work was used. Gains in existential well-being and quality of life post-dream work were measured using the Existential Well-Being Scale and the Spitzer Quality of Life Uniscale (Wright et al., 2015). The researcher (first author) provided up to two dream work sessions to each patient as well dream interpretation with a focus on personal meaning.
Results. Participants in this study had high scores on the measures of gains from dream interpretation. These results were in line with the qualitative findings as well as with previous research findings (Kerr et al., 2014; McGillicuddy, 2009; Wright et al., 2015). Dreams frequently echoed the concerns in the patients’ lives, such as interpersonal relationships and past experiences. The dream work interpretations were reported to be both comforting and meaningful, leading to new insights. Although some dreams were experienced as emotionally unpleasant, no adverse effects were disclosed as a result of the dream work.
Dreams and the Dying Process
This qualitative study by Lowther (2002) presents a non-sectarian spiritual vision of dream work through literature reviews, interviews, and a creative social action project that trained hospice workers in-service to work with patients’ end of life dreams. Scientific studies as well as interviews and mystical accounts of dreams at end of life were included. It was the author’s hope to further the understanding of dreams near death as well as to improve the quality of palliative care through the application of dream work.
Objective. Lowther (2002) presents a theory for working with dreams at end of life as a way of partnering, with those who are dying, in the spiritual aspects of end of life. Much like the theories on dreaming presented by Bosnak (2007) and Lyons (2012), Lowther’s (2002) proposes that dreamers have access through dreams to intelligence that is inaccessible during normal waking hours. The study inquires into various methods of working with and analyzing dreams from the perspective that dreams may hold the capacity to instruct us on ways of approaching death.
Method. The qualitative study by Lowther (2002) presents a literature review that includes the dying process of Tibetan and Indian Sant Mat traditions as well as shamanic and indigenous traditions. She reviews and discusses psychological studies of dream work as well as history and technique in hopes of supporting the rationale for dream work at end of life. In addition, Lowther (2002) participated in a creative social action project that developed a training program to help meet the need for dream work training in hospice workers.
Results. Three questions were examined in this study. The first explored the qualities of dreams that appeared to offer spiritual guidance at the end of life. The second question explored the ways in which end-of-life dreams can be analyzed to learn about participating in a beneficial way with those who are dying (Lowther 2002). Both were addressed by the literature reviews as well as through interviews with dreamers and their caregivers.
The third question investigated how insights gained through end-of-life dream work and related research can be transferred to those who could benefit. This question was addressed in two steps. The first step was to lead and organize an eight-week experiential dream work group for hospice workers. The second step was to develop and provide an in-service training of one and a half hours for hospice workers in seven hospices (Lowther, 2002).
Results support Lowther’s (2002) theory that dreams may be preparing the dreamer for death and that dreamers experience a “spiritual” nature to these dreams. Much as in the previously mentioned research (Kerr et al., 2014; McGillicuddy, 2009; Wright et al., 2015), dreamers experienced feelings of reassurance, comfort, and peace. In addition, a technique called dream incubation was used and showed promise as a means of working with dreams. Hospice workers reported a need for changing medical professionals’ attitudes about dreams to allow for a greater capacity to use them. The in-service training functioned efficiently, giving hospice workers dream working skills in a brief period of time.
This review suggests that dream work offers an effective method of helping those who are experiencing end-of-life dreams to find meaning and reassurance as well as to mediate existential crisis (Devery et al., 2009; Lowther, 2002, Kerr et al., 2014; Wright et al., 2015). However, existential significance in dreams is largely unexplored in clinical literature as well as in palliative care. Wright et al. point out that even though participants were in decline as they approached death, no substantial changes in existential well-being or quality of life were evident. Some participants reported low scores on the scales; nonetheless, they reported enjoyment and benefits of working the dream (Wright et al., 2015). Authors Kerr et al. (2014), McGillicuddy (2009), and Wright et al. (2015) point out that this study may support the hypothesis that palliative care is stronger in supporting physical symptoms than psychological well-being, as patients more commonly reported psychosocial concerns than physical worries.
A common thread among researchers was the need to train caregivers in advance to normalize end-of- life dream experiences, for both patients and their families, and use them as opportunities to support the dying in their existential suffering. Researchers found that dream work proved safe for the dying, a population that could be considered vulnerable due to declining health (Devery et al., 2009; Lowther, 2002, Kerr et al., 2014; Wright et al., 2015). No adverse events as a result of receiving dream work were reported. Caregivers often reported viewing dreaming as an important part of the dying process, helping the participants in reconciling with their impending deaths.
Lowther (2002) developed and tested a means of training hospice workers to work with the dreams of the dying in hopes that support for those experiencing end of life dreams will be more readily accessible. She also proposed integrating the incubation of dreams into dream workin a beneficial way,a method that is also endorsed by Bosnak (2007) but otherwise almost entirely overlooked.
A preponderance of the evidence reported here supports the efficacy of dream work with the dying. However, it is important to note that there is not a lot of research on the topic and the author may have been biased in her selection or reporting due to her own positive experiences with dream work, both as a patient and as a provider. In addition, there were some research limitations. For example, the majority of the studies reviewed here collected data from a relatively small number of subjects, and control groups were not used. Lowther’s (2002) research was based on a spiritual paradigm in which death is a passage from the earthly realm to a spiritual one. As is frequently seen when considering traditional holistic treatments, validation of paradigms such as this is not easily accomplished in a beneficial way as many of the concepts are not measurable.
Kerr (2009) pointed out a need to define terms and to consider the language we use when conducting dream research. For example, the research refers to “dreams while awake” as well as to visions without differentiating between them. Are “dreams while awake” vivid dreams that carry over into waking life, dreams or are they visions? Other considerations for future research include issues of diversity as nearly all subjects were Caucasian, and they were predominantly Christian. Kerr (2009) pointed out that in their study there was a notable absence of content that would be considered religious. However, in religiously and ethnically diverse populations, outcomes remain to be seen.
Although there is growing recognition that end-of-life dreams may hold some significance for the dying, there is a need for much more research, both quantitative and qualitative, to investigate a variety of strategies in enlisting end-of-life dreams to comfort the dying. A more holistic view toward both physical and psycho-spiritual wellness may need to be employed by medical practitioners made uncomfortable by end-of-life dreams. As there is sufficient data regarding the unmet psychological and spiritual needs of patients at end of life (Kerr, 2014), need for medical relevancy may dictate more qualitative research with clearly defined measures, including control groups, which do not receive dream work at end of life. In addition, future research that employs more evidence-based, quantitative measures of therapeutic efficacy would also help to support the integration of this methodology for end of life care.
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